Imagine a center where our seniors can receive transformative health care that will allow them to age at home and in their communities.
At Asian Health Services, we recognize that so many of our elderly patients continue to struggle to get the care they need because of challenges that go beyond the walls of the clinic.
To address these gaps, we’ve found a solution and model of care that integrates the quality care our elders receive at our health center with the most comprehensive support system, like transportation, culturally-inclusive meals, and social activities, our elders deserve.
We are building a Program of All-Inclusive Care for the Elderly (PACE) to bring life-changing, culturally competent care to low-income seniors—supporting them as they age safely and with dignity, right in their communities. Based on the PACE model, SpringLight Health will offer coordinated medical care, transportation, meals, social activities, medication management, and caregiver support—all tailored to each individual’s needs.
Learn more by visiting our website here.
Job Summary:
The PACE Intake Coordinator plays a critical role in ensuring that older adults and their caregivers can access the full benefits of the PACE model of care. As a key entry point into the program, this role helps determine participant eligibility, identify clinical and social needs early, and support a smooth transition into coordinated, person-centered care. The PACE Intake Coordinator works independently to set intake appointments, document incoming participants’ medical needs, and gather crucial medical and social information throughout the enrollment process by phone, in the participant’s home, and/or at the PACE Day Center.
Essential Job Functions
Referral management & pre-enrollment clinical coordination
- Receive, triage, and track referrals in collaboration with intake/enrollment staff; ensure referral completeness and prioritize based on acuity and program capacity.
- Conduct or coordinate initial clinical screening (phone/in-person) to confirm appropriateness for PACE and identify immediate risks or care needs.
- Obtain and review relevant clinical records (hospital/SNF notes, medication lists, problem lists, recent labs/imaging as applicable) to support eligibility determination and IDT review.
- Coordinate scheduling and completion of required pre-enrollment assessments (e.g., nursing assessment, social work, PT/OT, nutrition, behavioral health as applicable) and ensure timely follow-up on outstanding items.
- Conduct home visits as needed to assess initial level of care needs, functional status, and home safety/barriers.
- Complete level of care (LOC) assessments.
- Partners closely with the Outreach team, Enrollment RN, IDT, and center leaders to deliver a coordinated, participant-centered enrollment experience.
Eligibility support & enrollment readiness
- Partner with eligibility/enrollment staff to support Medi-Cal/Medicare eligibility workflows and provide clinical clarification when needed.
- Prepare clinical summaries for IDT intake review and enrollment decisions, including risk flags, functional status, and care needs.
- Ensure required consents, releases of information (ROI), and participant/caregiver education are completed and documented.
- Support participant and caregiver understanding of the PACE model of care and what enrollment entails (services, center-based care, 24/7 coverage, PCP assignment, pharmacy, transportation, etc.).
Documentation, compliance, and audit readiness
- Maintain accurate, timely, and complete intake documentation in the EHR/CRM per internal policy and CMS/DHCS requirements.
- Track intake timelines and required elements to ensure compliance with program standards, including IDT involvement and documentation of enrollment decisions.
- Support readiness for audits/site visits by maintaining well-organized intake files and evidence of required processes.
- Maintain current knowledge of and adhere to Medicare/PACE prohibited marketing practices and applicable outreach/marketing guidance.
Operations, performance, and continuous improvement
- Own intake pipeline visibility and performance reporting (e.g., referral volume, cycle time to screening, cycle time to IDT decision, conversion rate); identify trends and lead improvement actions.
- Facilitate regular intake huddles with the intake team and cross-functional partners (eligibility/enrollment, social work, therapies, clinic) to resolve bottlenecks and ensure smooth handoffs.
- Identify and escalate operational risks (capacity constraints, high-risk referrals, documentation gaps) to clinical/operations leadership.
Care transition into PACE
- Coordinate handoff from intake to ongoing care teams upon enrollment, including communication of clinical risks, pending needs, and initial care plan priorities.
- Ensure initial appointment scheduling (PCP visit, nursing follow-up, therapies) is aligned with participant needs and center capacity.
- Coordinate initial medication reconciliation and pharmacy setup in partnership with clinic nursing/pharmacy partners.
Relationship management & community outreach support
- Build and maintain relationships with key referral sources (health systems, SNFs, community providers, social services, CBOs) to facilitate high-quality referrals and clear expectations.
- Provide clinical education to referral partners about PACE appropriateness criteria and the intake/enrollment workflow.
- Closely track referral data and partner with PACE leadership to identify trends, bottlenecks, and improvement opportunities.
Minimum Qualifications
- Experience communicating with older adults and caregivers across diverse backgrounds; commitment to person-centered, culturally responsive care.
- Strong assessment, triage, and care coordination skills.
- Proficiency with documentation systems (EHR/CRM) and strong organizational skills.
- Graduate of an accredited School of Nursing.
- Active California RN license in good standing.
- 2+ years of clinical nursing experience (geriatrics, primary care, home health, SNF, hospital case management, or similar).
- Current BLS certification (or ability to obtain within an established timeframe).
- Valid driver’s license and ability to travel for home visits (as required).
- Ability to speak Cantonese and/or Mandarin.
Preferred Qualifications
- Experience with PACE, managed care, complex care management, or transitions of care.
- Experience working in interdisciplinary teams.
Certifications, Licenses, Registrations
- Active California RN license in good standing.
- Current BLS certification (or ability to obtain within an established timeframe).
Benefits That Support You
We're committed to supporting our team's well-being. Our comprehensive benefits package includes:
Health & Wellness
- 100% employer-paid medical, dental & vision coverage
- Acupuncture & chiropractic coverage
Time Off
- 12 vacation days
- 12 sick days
- 12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)
Financial & Retirement
- 403(b) with 3% employer contribution + up to 2% match
- Flexible Spending Account (FSA) & Dependent Care Assistance
Additional Support
- Commuter benefits
- Long-Term Disability Insurance
Please note: We are not seeking support from staffing agencies at this time. Direct applicants only.
